Provider Demographics
NPI:1588943641
Name:PERKINS, BONITA
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:PERKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:360 BEECH ST
Practice Address - Street 2:
Practice Address - City:NEWLAND
Practice Address - State:NC
Practice Address - Zip Code:28657-9670
Practice Address - Country:US
Practice Address - Phone:828-733-5889
Practice Address - Fax:828-733-9462
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1899101YA0400X
NC1375106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC106H0000XMedicaid